Education And Debate
Maternal and child health: is South Asia ready for change?
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7443.816 (Published 01 April 2004) Cite this as: BMJ 2004;328:816Data supplement
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Table A Potential low cost interventions that may improve maternal and child health in South Asia at health system level
Intervention Strength of evidence* Potential impact or effect size Relative ease of implementation Barriers or remaining issues before nationwide implementation Nutrition education to improve balanced energy protein intake and promotion of intake of iodised salt I Reduction of iodine deficiency of 80-100% Reduction in perinatal mortality demonstrated
Moderately easy for promotion of iodised salt use Nutrition education is time consuming and labour intensive. Could be integrated with other sectors e.g. education, family planning using mass media. Vaccination against tetanus twice during pregnancy I >95% for prevention of neonatal tetanus Relatively easy Public education and awareness Maternal malaria prevention and treatment (bed nets or presumptive therapy) I 25% reduction in low birth weight babies and reduction in perinatal mortality Requires functional health systems Selective benefit only in malaria endemic areas Recognition of high risk pregnancy and timely referrals II Despite misgivings, up to 50% reduction of maternal mortality shown in functioning health system settings Difficult outside of functional health systems Development of core indicators and targeted training programmes. Linkages needed between health providers and first level facilities
Intrapartum care of mother including facilitation of skilled birth attendance and clean birth I 15% reduction in perinatal complications and 4% reduction in maternal deaths Difficult in areas where skilled birth attendants are sparse Despite barriers and difficulties, must be an absolute goal for health systems in South Asia Regular iron folate and maternal low dose vitamin A administration II Reduction in rates of iron deficiency anaemia difficult to estimate but significant reduction in maternal mortality Compliance may be variable Regular availability and quality of tablets are key. Commensurate need for public education and an integrated programme of nutrition education Promotion of exclusive breastfeeding I Clear evidence of impact on mortality and morbidity reduction Counselling skills required No major barriers to widespread application. Especially required in early infancy Appropriate complementary feeding of infants and use of iodised salt I Improved complementary feeding strategies result in an average 0.35 Z score increment and improvement in survival rates Unlike complementary feeding the promotion and use of iodised salt is relatively easy Must be integrated with the overall nutrition education programme Management of diarrhoeal disease (including appropriate feeding and antibiotic use for dysentery) and oral replacement therapy I Evidence of benefit on morbidity and mortality Easy to implement Must be scaled up within health systems with assured availability of oral rehydration therapy and drugs Recognition and management of acute respiratory infection I Community management leads to 24-27% reduction in all cause under 5 mortality and 36-42% in pneumonia mortality Feasible for community health workers Requires better "hands on" training programmes for community health workers Promotion and administration of childhood vaccinations I Impact on health outcomes well established Easy Cold chain and vaccine availability remain issues Care of the low birth weight infant I Benefits of skin to skin care or appropriate early care established Easy but supervision needed Some cultural barriers exist to skin to skin care in South Asia, but feasible Recognition of serious neonatal illness, stabilisation and referral I Neonatal mortality reduced by 50% (76% for sepsis related mortality) if injectable antibiotics provided to community health workers Moderately difficult to train community health workers Strong demand for domiciliary or village based care in rural settings. Further evidence needed in health system settings Provision of contraceptives including injectable preparations I Efficacy (over 98%) of depot-Provera well established Easy No significant barriers to inclusion in primary care programmes Health education especially hand washing I Established efficacy of health and nutrition education in several studies, although rates of success vary Feasible Communication skills required. Limitations of restricted messages and media *Level of evidence: I=established evidence (both efficacy and effectiveness), II=intermediate evidence (efficacy but not effectiveness)
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